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Exhibits

Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes

Bolus the client with 1 L of 3% sodium chloride solution

Hold the insulin infusion

Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%

Alert the provider of the current blood glucose level.

Add 20 mEq of potassium chloride to the IV fluids.

Start a regular diet

Answer and Explanation

Correct Answer : D,E,F

A. Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes.
A blood glucose of 250 mg/dL is still high but does not require immediate carbohydrate administration. Carbohydrates are given in cases of hypoglycemia (blood glucose <70 mg/dL) or when transitioning from IV to subcutaneous insulin at lower glucose levels.
B. Bolus the client with 1 L of 3% sodium chloride solution.
The client’s sodium is already elevated (152 mEq/L), and hypertonic saline (3% NaCl) would worsen hypernatremia and increase the risk of neurological complications. Instead, hypotonic fluids (0.45% NaCl) are recommended once intravascular volume is stabilized.
C. Hold the insulin infusion.
HHS is managed with continuous insulin infusion to gradually reduce glucose levels. The blood glucose is still above the target range (250 mg/dL), so insulin should not be stopped prematurely to avoid a rebound in hyperglycemia.
D. Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%.
Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. This is a standard part of HHS treatment after initial fluid resuscitation.
E. Alert the provider of the current blood glucose level.
Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy. The provider should be informed to assess whether insulin titration or fluid changes are necessary.
F. Add 20 mEq of potassium chloride to the IV fluids.
Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness. Potassium replacement is required to prevent complications and maintain normal levels.
G. Start a regular diet.
Clients with HHS require gradual rehydration and glucose control before transitioning to oral intake. A regular diet is not appropriate until the client is stable, glucose levels are consistently controlled, and IV therapy is discontinued.

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Correct Answer is C

Explanation

A. Initiate an IV bolus of 0.9% normal saline 500 mL. The client already has elevated CVP and PAWP, which indicate fluid overload and poor cardiac function. Giving a fluid bolus would worsen pulmonary congestion, edema, and respiratory distress. Fluid restriction, rather than additional IV fluids, is usually necessary in decompensated heart failure.
B. Titrate IV dopamine at 8 mcg/kg/minute. Dopamine is a vasopressor and inotropic agent that increases blood pressure and cardiac output. However, the client has an elevated blood pressure (140/50 mm Hg) and signs of fluid overload, making dopamine unnecessary. Increasing contractility could further stress the failing heart and worsen congestion.
C. Administer furosemide 40 mg IV push (IVP). Furosemide (a loop diuretic) is the best intervention for fluid overload in heart failure. Elevated CVP and PAWP suggest pulmonary congestion and excess intravascular volume, which furosemide helps relieve by reducing preload and promoting diuresis. This intervention improves breathing, reduces blood pressure, and decreases cardiac workload.
D. Encourage a liberal PO fluid intake. Clients with heart failure often require fluid restriction to prevent worsening edema and pulmonary congestion. Encouraging excessive oral fluid intake would worsen fluid overload and should be avoided.

A. pH 7.25 and HCO₃⁻ 18 mEq/L B. pH 7.30 and HCO₃⁻ 20 mEq/L C. pH 7.38 and HCO₃⁻ 24 mEq/L D. pH 7.20 and HCO₃⁻ 15 mEq/L

Correct Answer is C

Explanation

A. pH 7.25 and HCO₃⁻ 18 mEq/L. A pH of 7.25 is still acidotic, and a bicarbonate level of 18 mEq/L is below the normal range (22–26 mEq/L), indicating persistent metabolic acidosis. This suggests that ketoacidosis is not fully resolved, requiring continued insulin therapy, hydration, and electrolyte management.
B. pH 7.30 and HCO₃⁻ 20 mEq/L. While this shows partial improvement, the pH remains below 7.35, indicating ongoing mild acidosis. The bicarbonate level is still below normal, suggesting that buffering capacity is not yet fully restored. Additional treatment is required to completely normalize acid-base balance.
C. pH 7.38 and HCO₃⁻ 24 mEq/L. A pH of 7.38 falls within the normal range (7.35–7.45), indicating that acidosis has resolved. The bicarbonate level of 24 mEq/L is within normal limits, confirming that the body’s buffering system has been restored. These values suggest that ketoacidosis has resolved, and treatment has been effective.
D. pH 7.20 and HCO₃⁻ 15 mEq/L. A pH of 7.20 indicates severe metabolic acidosis, and a bicarbonate level of 15 mEq/L shows a significant loss of buffering capacity. These values suggest uncontrolled DKA or worsening acidosis, requiring urgent intervention with continued insulin therapy, fluid resuscitation, and electrolyte replacement.

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Exhibits Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Exhibits Complete the following sentence by choosing from the lists of options. A pH level of ________ and bicarbonate (HCO3-) level of________indicate a resolution of ketoacidosis.

Correct Answer is C

Explanation

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Exhibits

Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.